CASE REPORT

Korean J Obstet Gynecol 2011;54(4):218-222

doi: 10.5468/KJOG.2011.54.4.218
pISSN 2233-5188 eISSN 2233-5196

OVARIAN DYSGERMINOMA ASSOCIATED WITH

PREGNANCY
Yoon Kyung Lee, MD1, Chang Young Yoo, MD, PhD2, Guisera Lee, MD, PhD1, Dong Choon Park, MD, PhD1
Departments of 1Obstetrics and Gynecology, 2Pathology, St. Vincents Hospital, The Catholic University of Korea School of Medicine, Suwon, Korea

A case of a 33-year-old 3 gravida, 1 para pregnant woman in the 7th week of gestation who was concurrented with dysgerminoma
is presented. Measurements were made on serum lactic dehydrogenase, alpha-fetoprotein, CA-125, and pelvicmagnetic resonance
imaging. The clinical stage was IA and right salpingo-oophorectomy and biopsy of the left ovary were done preserving the
pregnancy. A cytological finding was non-specific. The frequency of malignant ovarian tumors associated with pregnancy and the
treatment for it were discussed.
Keywords: Dysgerminoma of ovary, Pregnancy

It has been reported that an ovarian dysgerminoma originates

from the germ cell of the ovary. The name dysgerminoma proposed by Meyer in 1931. Dysgerminoma was investigated histologically. Diagnosis was made on serum lactic dehydrogenase
(LDH), alpha-fetoprotein (AFP), as a tumor maker and serum LDH
was considered to be an indicator of therapeutic effects. Dysgerminoma is malignant and tends to occur in young women, though
the incidence of pregnancy with dysgerminoma is extremely low.
This paper presents a dysgerminoma which developed in a patient
in the seventh week of pregnancy and performed conservative operation for preserving pregnancy with laparoscopy.

Case Report
A 33-year-old housewife, 3 gravida, 1 para pregnant woman was
transferred for early pregnancy with Rt. ovarian tumor. Her menarche was at the age of 12 years and she has regular menstrual
cycle of 28 days. The patient noticed a mass in her lower abdomen
during her antenatal care and transferred to our hospital. At her
first visiting, she was at the end of 7th week of pregnancy and
she complains the emesis. Pelvic examinations disclosed that a
soft goose-egg-sized uterus was associated with a hard tumor of
infants head-size at its front. She was diagnosed as being in the
seventh week of pregnancy, and the co-existence of solid ovarian tumor was also suggested. She was admitted to the hospital.
She was 165 cm tall and weighed 53 kg. Her blood pressure was
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120/70 mm Hg and her pulse rate was 84/min. No abnormalities were seen on the general findings. In Laboratory tests, the
blood was type B, Rh-positive. No abnormality was observed in
hematological test results. -human chorionic gonadotropin (hCG)
was measured as 75929.15 mIU/mL. As regards blood chemistry,
LDH was 408 U/L, AFP was 13,464 ng/mL, CA-125 was 57.20
U/mL, CA 19-9 was 13.50 U/mL, and carcinoembryonic antigen
(CEA) was less than 0.50 ng/mL. There were no abnormalities in
urinalysis, electrocardiogram, pulmonary or respiratory data. Ultrasonography revealed that the uterus was 78 cm in size and had
a gestational sac (GS) in its center. At the posterior of the uterus,
there was a shadow of mass measuring 101114 cm. The mass
had multilocular profiles with some solid parts, and its wall looked
slightly thick (Fig. 1).
Pelvic magnetic resonance imaging (MRI) without enhance was

Received: 2011. 3. 6. Accepted: 2011. 3.28.

Corresponding author: Dong Choon Park, MD, PhD
Department of Obstetrics & Gynecology, St. Vincents Hospital,
The Catholic University of Korea School of Medicine, 93 Gi-dong,
Paldal-gu, Suwon 442-723, Korea
Tel: +82-31-249-8221 Fax: +82-31-254-7481
E-mail: dcpark@catholic.ac.kr
This is an Open Access article distributed under the terms of the Creative Commons
Attribution Non-Commercial License (http://creativecommons.org/licenses/
by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and
reproduction in any medium, provided the original work is properly cited.

Copyright 2011. Korean Society of Obstetrics and Gynecology

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Yoon Kyung Lee, et al. Ovarian dysgerminoma associated with pregnancy

Fig. 1. Ultrasonographic findings. (A). Fetal heart rate is normal (B). The mass had multilocular profiles with some solid parts, and its wall looked slightly
thick (C). The vascularization of tumor mass was checked and the resistance index (RI) was calculated. RI=0.33 (D).

Fig. 2. Pelvic magnetic resonance imaging without enhance was perfomed. It measured a 5.89.8 cm in sized and was a lobulating contoured mass with
intermediate signal intensity in T2 images. And a 4.33.3 cm sized cystic lesion was also observed. (A) Sagittal view. (B) Axial view. Arrows: dysgerminoma.

performed. The mass mostly occupied the posterior pelvic cavity

and impacted into the Douglas pouch as shown in Fig. 2. It measured a 5.89.8 cm in sized and was a lobulating contoured mass

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with intermediate signal intensity in T2 images. And a 4.33.3

cm sized cystic lesion was also observed. Its wall was sometimes
thin and sometimes thick. On the basis of these findings, the mass

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Fig. 3. Laparoscopic finding. Laparoscopic right adnexectomy and contralateral ovary biopsy were performed.

Fig. 4. Microscopically, monotonous polygonal cells form well defined nests separated by fibrous stroma (A: H&E, 100). In certain area tumors cells
form cords or trabecular patterns (B: H&E, 400).

was diagnosed as the granulosa cell tumor which occurred in the

right ovary. Laparoscopic right adnexectomy and contralateral
ovary biopsy were performed. About 10 cm sized and a relatively
hard tumor with smooth surface was found in the median portion
of Douglas pouch, slightly extended to the left of the pelvic cavity
(Fig. 3). The tumor originated from left ovary. It was partly cystic
but mostly solid. Microscopically the tumor cells have prominent
cell membrane, abundant pale to granular cytoplasm and uniform
nuclei having prominent nucleoli. In the fibrous stroma, variable
amounts of chronic inflammatory cells especially lymphocytes are
found. And occasional mitoses are found (Fig. 4).

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Discussion
Pregnancy induces dynamic changes in endocrinological activity throughout the female lives. Therefore such assumption may
not be always misdirected that various ovarian tumors, especially
malignant tumors derived from germ cells, are apt to appear during pregnancy. However, a few cases of dysgerminoma associated
with pregnancy have been reported up to now.
The rate of malignant tumors in the total number of ovarian
tumors associated with pregnancy was reported from 1.3% to
7.9% [1]. In our clinic, the rate of malignancy was very rare as less
than 1%. This is markedly lower than that of the patients without
pregnancy. From these facts, it may be said that the rate of the
malignant ovarian tumors associated with pregnancy is rather low.

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Yoon Kyung Lee, et al. Ovarian dysgerminoma associated with pregnancy

Beischer et al. [2] have explained that such differences in the rate
of malignant ovarian tumor are caused by the difference in age
distribution between non-pregnant and pregnant women. Most of
the patients with malignant ovarian tumor were over 40 years old
and those patients were rarely pregnant [2]. In our clinic, 62.2%
of the patients with malignant ovarian tumor belonged to the
group of 40 years old or more. Dysgerminoma is considered to be
one of the most common ovarian tumors in reproductive age [3-5].
Fortunately it is rather rare but unfortunately the management for
a gynecologist to encounter patients who have developed dysgerminoma during pregnancy has not well known.
How pregnancy influences dysgerminoma or how dysgerminoma
influences pregnancy has been discussed. Bakri et al. [6] reported
that the association of pure dysgerminoma and pregnancy did not
adversely affect the tumor prognosis or fetal outcome. In our patient, neither clinical, histological nor cytological findings indicated
that dysgerminoma were not influenced by pregnancy. Malignant
ovarian tumors associated with pregnancy tend to progress asmyptomaticcally and there are no differences with benign ovarian
tumors in early stages. Therefore, we are facing some difficulties
in making a correct diagnosis of ovarian cancer in pregnancy. In
some patients, they complained bearing down sense or pressure
in the lower abdomen, when the ovarian tumors had grown up to
some extent. But a huge gravid uterus makes pelvic examinations
insufficient, and also it is impossible to conduct computed tomography (CT) scan. Occasional ultrasonography should be performed
in order to confirm whether ovarian tumor is present or not. It is
very useful to evaluate whether tumor is cystic or solid. In general,
non-enhanced MRI is relatively accurate and recommended. The
LDH value is hard to work as the indicator of malignant ovarian
tumor when the patient is pregnant.
The treatment of ovarian malignant tumor with pregnancy is as
difficult as the diagnosis. Because of the very few cases theres
lack of statistically significant experience world-wide. Therefore
debate is even further. Concerning the treatment of ovarian cancer, Disaia et al. [7] proposed the following eight conditions to
conduct conservative operation; 1) cancer classified as stage Ia, 2)
well differentiated mucinous, endometrioid or mesonephric histology 3) a young woman of low parity, 4) otherwise normal pelvis,
5) encapsulated and free of adhesions, 6) no invasion of capsule,
lymphatics, or mesovarium, 7) peritoneal washings negative, 8)
ovarian wedge biopsy and omental biopsy negative, and 9) close
follow up. Munnell [8], and Graber and Barber [9] also indicated
that when low grade mucinous cyst-adenocarcinoma, arrhenoblastoma, dysgerminoma, granulosa theca cell tumor or low grade

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papillary tumor is observed at its Stage Ia during pregnancy, the

disease can be treated only by resection of an affected ovary.
In our case, we performed unilateral adnexectomy and contralateral ovarian biopsy. Grossly the tumor was confined within
one ovary and its capsule was intact. In frozen biopsy of contralateral ovary and cytology was negative. We enveloped the tumor
mass twice with endopouches and removed it out through the
12 mm trocha incision site which extended to 15 mm. During the
operation tumor cells were not spilled. After operation we check
the fetal health and the fetus had not any problem. We planned
the post-operative follow-up with ultrasonography and LDH comparing with initial value. And non-enhanced pelvic MRI is also
checked occasionally.
Our hospital also had no statistical data for treatment or prognosis of dysgerminoma during pregnancy. Especially whether it may
have no problem to performed resection of affected side adnexae
only or not. But in my opinion, after giving general information
about dysgerminoma to parents conservative management may
be enough in stage Ia dysgerminoma if they agree.

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